Do You Inject The Plantar Fascia On The First Visit For Plantar Heel Pain?

Over the past 12 months, I have treated three patients who presented with an acute rupture of the plantar fascia. Two of these patients were serious long-distance runners who experienced a crippling “pop” on the bottom of the foot during a run. The other patient tore his fascia pushing an automobile down the street. All three patients had experienced chronic heel pain for several months prior to their acute injury and none of them had ever received a corticosteroid injection.

This experience underscores my 30 years of practicing sports medicine, during which I have seen many patients who suffered a traumatic tear of the plantar aponeurosis. The vast majority had never received a corticosteroid injection prior to their injury. Yet there continues to be controversy about the use of corticosteroid injections in patients with plantar heel pain syndrome.

Last year, the American College of Foot and Ankle Surgeons (ACFAS) published a revised clinical practice guideline for the treatment of plantar heel pain.¹ These guidelines are based upon scientific evidence and the panel provides specific treatment recommendations based upon the strength of this evidence. The manuscript is well constructed by a panel of podiatric physicians who propose that there are multiple causes of heel pain and one must first determine the etiology before initiating treatment. Furthermore, the panel of authors recognize the term “plantar fasciitis” may be a misnomer as the scientific evidence indicates that this syndrome is actually a degenerative condition, which should be labeled as a “fasciosis.”

What might surprise some practitioners is the position taken by the panel on the use of corticosteroid injections in the initial treatment of plantar heel pain.¹ The guidelines advocate the use of this treatment with a Grade B level of evidence. In other words, corticosteroid injections are listed as a Tier 1 treatment option along with stretching and arch taping.

However, a recent article in Lower Extremity Review by Groner points out the divergence of opinion about the use of steroid injections for heel pain.² Groner contrasts the guidelines for treatment of plantar heel pain published by ACFAS with the recent publication of guidelines by the American Physical Therapy Association (APTA).³ While the ACFAS found incomplete evidence for the benefits of physical therapy, the APTA found ample evidence. Also, the APTA made no mention of corticosteroid injections.

Groner also quoted a podiatrist and a physical therapist who strongly condemn the use of corticosteroid injections in the initial treatment of patients presenting with plantar heel pain.³ They speculated that corticosteroids would weaken the fascia and would only cover up symptoms without providing any true healing.

I am less skeptical of the use of corticosteroid injections in the treatment of plantar heel pain. I am aware of many studies documenting the effects of steroids on tendons and connective tissue, and I realize there can be benefit in reducing collagen hypertrophy, which abounds in plantar fasciosis. I am not worried about spontaneous rupture for the aforementioned reasons. I am in agreement with the ACFAS treatment guidelines as there are cases in which a corticosteroid injection is indicated as a Tier 1 intervention.

I am curious what my colleagues think about this controversy and invite you to share your views.

References

1. Thomas JL, Christensen JC, Kravitz SR, et al. The diagnosis and treatment of heel pain: a clinical practice guideline-revision 2010. J Foot Ankle Surg 2010; 49(3 Suppl):S2.

2. Croner G. Heel pain revisited: new guidelines emphasize evidence. Lower Extremity Rev. 2010; 2(6):14-20. Available at http://www.lowerextremityreview.com/cover_story/heel-pain-revisited-new-... [2] .

3. McPoil TG, Martin RL, Cornwall MW, et al. Heel pain—plantar fasciitis: clinical practice guidelines. J Orthop Sports Phys Ther 2008; 4(38):A1–18.